Clostridioides Difficile Infection (CDI) in children (<16 years of age)

Publication: 08/09/2016  --
Last review: 21/01/2021  
Next review: 21/01/2024  
Clinical Guideline
CURRENT 
ID: 4731 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Clostridioides Difficile Infection (CDI) in children (<16 years of age)

Diagnostics

Symptoms or clinical signs cannot be used to reliably distinguish CDI from other causes of diarrhoea in children.

CDI diagnosis requires either laboratory confirmation or visualization of pseudomembranes on sigmoidoscopy or colonoscopy. [Evidence level B]

It is not recommended to conduct routine testing for CDI in children younger than 2 years (carrier state rate or gut colonisation is highest in this age group) and consider other causes of diarrhoea, particularly viruses.

For patients with a presumed diagnosis of CDI the following diagnostic tests should be taken to confirm diagnosis:

All patients (≥2 years) with symptoms of diarrhoea (type 5-7 on Bristol Stool Chart) and no clear alternative cause should have a stool sample sent marked for C. difficile testing.

All patients should have: FBC, CRP and U&E’s

Patients who were initially excluded clinically, but still have persistent symptoms (>48 hours) of diarrhoea (type 5-7 on Bristol Stool Chart) after action taken to correct diarrhoea, should have a stool sample sent marked for C. difficile testing.

In suspected cases of ‘silent’ CDI, such as ileus, toxic megacolon or pseudomembranous colitis without diarrhoea, request abdominal imaging e.g. abdominal x-ray, CT scanning or abdominal US. 

Patients with severe infection should have serum lactate measured on a daily basis until clinical signs of improvement or surgical intervention is required.

Please see Clostridioides difficile (previously known as Clostridium difficile); Guideline for the prevention of transmission in adults and children >2 years with Clostridioides difficile Infection (CDI) for further information about investigations, diagnosis and source isolation.

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Severity assessment

Patients with a confirmed CDI should be assessed daily for severity of infection including signs and symptoms of colitis.

Severity assessment of Clostridiodes difficile infection in children

Total score:
1–2=mild disease.
3–4=moderate disease.
≥5=severe disease.

Criteria

Points

Diarrhoea >5 times a day

1

Abdominal pain and discomfort

1

Rising white cell count

1

Raised C-reactive protein (CRP)

1

Pyrexia >38°

1

Evidence of pseudomembranous colitis

2

Intensive care unit requirement

2

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Empirical treatment

Any concurrent antibiotics should be stopped wherever possible or substituted for an agent with lower risk of inducing CDI if an underlying infection still requires treatment.

If a patient is taking a Proton-pump inhibitor (PPI) this should be reviewed and stopped where possible. 

Empirical options for CDI

Severity

Recommended treatment

Notes

Duration

Mild severity

If symptoms are settling by time of CDI confirmation there is no need to treat. It treatment is felt appropriate follow the regimen for moderate severity.

Moderate severity

1st Line Option3

Enteral Vancomycin electronic Medicines Compendium information on Vancomycin 2:

  • Child 1 month- 11 years: 10mg/kg (max. 125mg) every 6 hours
  • Child 12-16 years1 125mg every 6 hours

2nd Line or if Vancomycin unsuitable

Oral Metronidazole electronic Medicines Compendium information on Metronidazole:

  • Child 1-2 months: 7.5mg/kg every 12 hours
  • Child 2 months-12 years: 7.5mg/kg (max. 400mg) every 8 hours
  • Child 12-16 years1 400mg every 8 hours

For patients who are nil by mouth, Metronidazole electronic Medicines Compendium information on Metronidazole can be given IV (at the same dose).

Formulations available for Vancomycin electronic Medicines Compendium information on Vancomycin:

  • 125mg and 250mg capsules
  • 50mg/ml enteral liquid (hospital only)

Formulations available for Metronidazole electronic Medicines Compendium information on Metronidazole:

  • 200mg and 400mg tablets
  • - 200mg/5ml enteral liquid

10 days

Severe

Enteral Vancomycin2:

  • Child 1 month- 11 years: 10mg/kg every 6 hours, increased to 500mg/dose in life threatening infections
  • Child 12-16 years1 125mg every 6 hours, increased to 500mg every 6 hours in life threatening infections.

Formulations:
- 125mg and 250mg capsules
- 50mg/ml enteral liquid (hospital only)

AND

IV Metronidazole electronic Medicines Compendium information on Metronidazole

  • Child 1-2 months: 7.5mg/kg every 12 hours
  • Child 2 months-12 years: 7.5mg/kg every 8 hours (max. 500mg/dose)
  • Child 12-16 years1 500mg every 8 hours

Surgical review may be indicated if evidence of caecal dilatation on imaging.

Review at 10 days

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Recurrent CDI and treatment failure

Recurrence of CDI is usually defined as recurrence of diarrhoea (at least 3 consecutive type 5-7 stools) and a positive C. difficile toxin assay within 30 days of a previous CDI episode and after resolution of previous symptoms (i.e. no diarrhoea for at least 48 hours).

Treatment failure should not be assessed before day 7 of therapy.

Diarrhoea should resolve within 1-2 weeks, if diarrhoea has improved but persists at 14 days but the patient is otherwise stable, the WCC is normal, and there is no abdominal pain or distension, the persistent diarrhoea may be not due to infectious cause.

Do not retest C. difficile toxin positive cases if patients are still symptomatic within a period of 28 days unless symptoms resolve and then recur and there is a need to confirm recurrent CDI. 

1st recurrence

The regimens used to treat patients with first episodes of C difficile associated colitis can be repeated for the first recurrence.

2nd or later recurrence

Second or later recurrences should typically be treated with Vancomycin electronic Medicines Compendium information on Vancomycin, using a higher dose (up to 2 g/day). In patients with multiple recurrences, a tapered and/or pulsed regimen may be considered after discussion with specialist in microbiology/ infectious diseases.
An acceptable tapered regimen is as follows:

  • 40 mg/kg/day in four divided doses for 10 to 14 days (10 mg/kg per dose, maximum 125 mg per dose); then
  • 10 mg/kg per dose twice per day for one week; then
  • 10 mg/kg per dose once per day for one week; and finally,
  • 10 mg/kg per dose every two or three days for two to eight weeks.

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Footnotes

  1. Doses taken from cBNF state for children aged 12-18 years. The age has been amended 12-16 years in this guideline to prevent confusion between adult and paediatric guidelines.
  2. Vancomycin oral liquid 50mg/ml prepared as extemp in dispensary. 7 day expiry -ensure adequate arrangements made for supply for discharge
  3. Data on the relative effectiveness (measured as treatment failure) of metronidazole compared to vancomycin is limited in children. IDSA/SHEA guidelines [McDonald, 2018] advise that for ‘mild’ disease, clinicians may choose either agent. However, the limited data does show a trend toward vancomycin being more effective, but this evidence can be considered weak quality, and is not statistically significant. Therefore, clinicians may choose either but should consider:
    • availability and palatability of formulations
    • dose and administration instructions
    • allergy status

Provenance

Record: 4731
Objective:
Clinical condition:

Clostridioides Difficile Infection (CDI)

Target patient group: Paediatric patients with Clostridium difficile infection
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence Base

  • AAP COMMITTEE ON INFECTIOUS DISEASES Clostridium difficile Infection in Infants and Children DOI: 10.1542/peds.2012-2992 Paediatrics 2013;131;196; originally published online December 31, 2013
  • Bolton, R.P. and M.A. Culshaw, Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut, 1986. 27(10): p. 1169-72.
  • Campbell. C, Poisson. M, Hand, E. An Updated Review of Clostridium difficile Treatment in Paediatrics. The Journal of Paediatric Pharmacology and Therapeutics. 2019 24(2)
  • McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):e1-e48. doi: 10.1093/cid/cix1085. PMID: 29462280; PMCID: PMC6018983.
  • Pai S, Aliyu SH, Enoch DA, Karas JA (2012) Five Years Experience of Clostridium difficile Infection in Children at a UK Tertiary Hospital: Proposed Criteria for Diagnosis and Management. PLoS ONE 7(12): e51728. doi:10.1371/journal.pone.0051728
  • Wilcox, M.H. and R. Howe, Diarrhoea caused by Clostridium difficile: response time for treatment with metronidazole and vancomycin. J Antimicrob Chemother, 1995. 36(4): p. 673-9.
  • Zar, F.A., et al., A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis, 2007. 45(3): p. 302-7.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.1

Related information

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